Croup

Grades:

Exertional stridor only with exercise

At rest stridor

With retraction subcostal & intercostal

With Resp. failure cyanosis

1, 2 outpatient treatment
3, 4 hospitalization

Types:

Bacterial: epiglottitis, tracheitis high grade fever, anorexia, flushing,

toxic, bad general condition organism is Staph. Aureus

Viral: laryngitis, lanyrgo-bronchitis

Laryngo-tracheobronchitis with wheezy chest

No tongue depressor in any case of croup epiglottitis

Stridor is more common at night due to more congestion

Treatment

Humidify the vocal cords

At the reception
Warm saline or
Epinephrine, racemic: 0.01 mg/kg/dose (ampule 1mg/1ml)
10

At home
Vapozol ( )
10

2 agonists are contraindicated broncho-dilatation dead space of

bronchi gas exchange in the alveoli

Antitussive is contraindicated

Corticosteroids

Injection (at the hospital)

Dexamethasone

Trade name: apidone, Fortecortin, dexamethasone, decadron,

epidron

Ampule: 8mg/2ml

Dose: 0.25-0.5 (0.4) mg/kg/dose

Takes 3-4 hours to work

Can be repeated

Hydrocortisone

Fast take hour to work

Dose: 5-10 mg/kg/dose

Solu-Cortef (100mg/2ml) 10

Sigmacortin (500mg/5ml) 1 10

Oral (at home)

Oral steroids maximum for 3 days if longer gradual

Dexamethasone

0.1-0.2 mg/kg/day

Trade name: apidone, vendexine, Orazone, phenadol (0.5mg/5ml)

1 3

Prednisone

Dose: 1-2 mg/kg/day

Trade name: Predsol, Xilone (5mg/5ml)

Iron Deficiency anemia

Diagnosis and investigation

Serum ferritin

HB electrophoresis

RDW >20% in Fe def. anemia

 or Normal in thalassemia

Treatment

Oral iron 6mg/kg/day for at least 3 months

Ferose 50mg/5ml ( disadvantage Fe in the form of ferric require
Gastric Hcl to be active

Sytron 27.5mg/5ml ( little amount per 1 ml)

Ferretal 35mg/5ml

Gastroenteritis (plan C)
Renal failure:

Urine output 1ml/kg/hour

Blood pressure pre renal failure

Metabolic acidosis: cosmol breathing D.D from grunting

Investigation

Renal function tests

ABG

RBS DKA

Chest x-ray

Aminoaciduria metabolic acidosis

Oliguria challenge test

10-20 mg/kg ringer IV
Or lasix 1-2 mg/kg
No 5mg/kg/dose
Another 1 hour if still no 10mg/kg/hour

Antibiotics
Macrolides

Oral except azithromycin

Taken for 7 days

Active against:

G +ve

E.Coli Gastroenteritis

Klebsiella, mycoplasma atypical pneumonia

Erythromycin
Against G +ve Upper airway (sore throat)

Dose 30-50 mg/kg/day ( average 40 mg )

Trade name: erythromycin, erythrocin, erythrin syrup

( 200mg/5 ml every 1 ml = 40 mg)

Dosage =

Primomycin (erythromycin + sulpha) 6-8 h

1 ml (1 cm3) / kg / day

Clarithromycin
Dose: 15 mg/kg/day divided over (/12 h)

Klacid : 125, 250

Klarimix: 125

Used in

1cm = 25 mg

=> 3cm/5 kg

Upper airway: bronchiolitis Asthmatic

Atypical pneumonia: mycoplasma, Klebsiella, 6

, (febrile pneumonia)

Roxithromycin
The only in form of suppositories

Dose: 5mg/kg/day

Used in upper airway

Azithromycin
Used in

Sore throat

Otitis media

GE

UTI

Atypical pneumonia

Typhoid: dosage in typhoid is 20mg/kg/day for 7 days

Eradication of post streptococcal GN: (Used for 10 days) (main

symptom red urine, urea, creatine)

5 days

Used at least for

Used once daily, before meal by 1 hour or after meal by 2 hrs.

Dose: 10 mg/kg/day

Dosage

Syrup (30 ml 60 ml 90 ml)

100mg/ 5 cm as in zithrokan, unizithrin, zisrocin

WT/2

2 100

200mg/ 5cm as in zithrokan, Zithromax, xithrone,

aziwok, zithrodose

WT/4

4 200

Chloramphenicol: NOT used

Sulpha

2 years old

Not used before

Active against E.Coli, G +ve

Dose: 1ml / 2kg/ day WT/2

Divided /12h

Bacteriostatic used more than

Uses

Sore throat

UTI

GE

Bacillary dysentery

>7

days

Form and dosage

Syrup [not suspension, no injection]

Septazole, septrin, sutrim

Septazole tab: 12

Beta-lactamase

Only in the form of injection,

Active against: G +ve, G ve, anaerobes

Mainly in neonates in hospitals

Names: imipenem, meropenem

Dose: 20 mg/kg/dose divided over /8h

gm. / 100cc

Uses

Severe neonatal sepsis

Meningitis: dose 40 mg/kg/day

Pseudomonas

Vancomycin

Anti-staph

Only injection

Dose 15 mg/kg/dose divided over /8h

Trade name: vancomycin merk

Used in

Pneumonia

Pseudomembranous colitis

Anti-staph drugs

Ampicillin

Fluxacillin

Garamycin

Convulsions
First time
Neonates most used phenytoin
Pediatric first drug of choice is diazepam

Diazepam

Dose: 0.3-0.5 mg/kg/dose

Trade names: neuril, valpam => 5mg/ml

Dosage =

If febrile convulsions rectal

IV over 10 minutes
For

3 successive doses if no improvement

Phenobarbitone

Trade name: sominelatte

Dose

Loading dose: 15-20 mg/kg/dose

Maintenance dose: 5mg/kg used when convulsions is

controlled

Dosage:
Sominelatte = 40mg/1ml
10
10 / 1 ,-- 3
2
10 10
10 1 / 1

For

3 successive doses if no improvement

Phenytoin

Dose: 15-20 mg/kg/dose

Trade name: epanutin 250mg/5ml

Every 1ml = 50 mg
4 1
10 2
10 / 1

Maintenance 5mg/kg
For

3 successive doses if NO improvement

Midazolam

Loading dose: 0.1-0.2 mg/kg/dose

Trade name: dormicum 5mg/1ml

Dosage:
1 1
4 1
10 1
=
0.1
shots
If not infusion = 0.05 mg/kg/hour

24

100
/ / 1

First line therapy in convulsion is neuril but contraindicated in neonates

Antiepileptic
Depakine first line in most of cases
2 nd attack
EEG prognostic value, determine site affected frontal, temporal,
Depakine in all except
Partial complex seizures tegretol [carbamazepine]
Infantile spasms (salaam attack) ACTH

Rickets
Definition: failure of mineralization of Ca in bone

Causes:

Breast feeding: milk is deficient in Vit. D, Vit. K

From the 4th month prophylactic dose of vitamin D

Cow milk:

Contraindicated in pediatric < less than 1 year

Cow milk allergy, type 1 D.M, bronchial asthma

High in phosphorus Ca absorption

Micro-hemorrhage in intestine

Buffalo milk is contraindicated before 6 months

Ultraviolet rays exposure

phytates in foods

Clinical picture

Early

Cupping, broadening: wrist joint

Craniotabes: ping pong skull

D.D from
Osteogenesis imperfecta all the skull

Rickets Parietal bone

Rosary beads: at costochondral junction

Marfan sign

Late

Box shaped skull

Pigeon chest

Harrison sulcus

Pot belly abdomen, visceroptosis , laxity of ligaments

Kyphosis, kyphoscoliosis
Kyphoscoliosis Co2 narcosis, congenital hypoventilation syndrome

Legs: bowing, coxa valga

Investigations
X-Rays: on 2 wrists, 2 ankles
Active: cupping, frying, double periosteum, rarefaction
Healing
Healed

Serum Ca/ phosphorus level

Alkaline phosphatase

Treatment
Active Vitamin D
Therapeutic:
Stooth therapy
Devarol once 600,000 unit
3 200000
+ Oral Ca with it or 1 day before it

15

To prevent hypocalcemia
Dosage: Hical 50-70 mg/kg/day
) (

If good healing rickets oral Vitamin D
Therapeutic dose: 3000-5000 unit/day
Prophylactic dose: 400-600 unit/day
Trade name:
Decal 1000 unit/5ml
Vidrop: 100unit/drop
Pedical: 400 unit/5ml
Dosage:
15cm decal = 3000 unit 5cm/8h 8 5

10

For 1 month
To avoid vitamin D toxicity [fever, rash, alertness, jaundice,
flushing]
Prophylactic dosage: from 4th month to 1 years
Decal 2cm/day
Pedical 5cm/day
Vidrop 4 drops/day
{ }


It is said that the famous sophist Protagoras took on a student, Euathlus,
on the understanding that the student pay Protagoras for his instruction
after he had won his first case (in some versions: if and only if Euathlus
wins his first court case). Some accounts claim that Protagoras demanded
his money as soon as Euathlus completed his education; others say that
Protagoras waited until it was obvious that Euathlus was making no effort
to take on clients and still others assert that Euathlus made a genuine
attempt but that no clients ever came. In any case, Protagoras decided to
sue Euathlus for the amount owed.
Protagoras argued that if he won the case he would be paid his money. If
Euathlus won the case, Protagoras would still be paid according to the
original contract, because Euathlus would have won his first case.
Euathlus, however, claimed that if he won then by the court's decision he
would not have to pay Protagoras. If on the other hand Protagoras won
then Euathlus would still not have won a case and therefore not be obliged
to pay.
The question is: which of the two men is in the right?

Antipyretic

Paracetamol

Safe from 1st day of life

Not effective if fever is > 38 c as it work in peripheral PG

Dose: 10-15 mg/kg/dose for 3-4 times /day

11

Form/ trade names/dosage

Drops
Cetal, pyral 5mg/drop
20 = 1 =
2 drops/kg/dose

Suppositories
Pyral 125
Cetal 125
Pyral 250
In 125 12

Syrup [PAC]

Pyral syrup:120 mg/5ml 1cm = 2.5 kg dosage=

WT/2

Abimol syrup: 150mg/5ml 30mg/1ml 1cm = 3 kg

dosage= WT/3

Cetal syrup: 250mg/5ml 50mg/1ml 1cm = 5 kg

dosage = WT/5

Tablets: Cetal 500 mg

Ibuprofen

Not before 1 year old

Dose: 10-15mg/kg/dose

Forms/dosage/trade names

Drops Flabu

Brufen syrup: 100mg/5ml 1 2 dosage =

WT/2 (2 )

Suppositories: macrofen 100mg ( for 10 kg) or 300 mg ( for

30 kg)

Paracetamol + ibuprofen
Cetafen, megafen: 100 mg ibuprofen + 162.5 paracetamol
2 ( WT/2)

Acetyl salicylic acid

Contraindicated in pediatric till 12 years old

Dose: 10-15 mg/kg/dose

Only used is Aspegic central effect pass blood brain

barrier on Amino acid Alanine
Aspegic 500mg/5ml 1ml/100 mg 1ml = 10 kg

Diclofenac Na

12

Dose: 0.5-1 mg/kg/dose

Not safe before 1 year

Dosage/ forms/ trade names

Drops: dolphin K

Suppositories: dolphin, baby relief, adwiflam

12.5 Or 25 or 50 mg

injection: voltaren, dolphin, epifenac 75mg/3ml

1cm = 25 kg
2 =

2
Olfen 75mg/2ml
3

ketoprofen

dose: 0.5-1 mg/kg

trade name: ketofan syrup

nimesulide

dose: 2-3 mg/kg/dose

trade names/ dosage

2 Nimesulide, nilsid, nimalox 50mg/5ml 1

Drug doses

Antiemetic

Primperan (0.5 mg/kg/day)

Ampule 10mg/2ml 24

TTT of overdose Avil 40 injection

Phenergan syrup

Drops: (drop = 0.1mg) 8

Domperidone (1mg/kg/dose)

Motilium, Motinorm

Oral syrup 1

Suppositories: 10mg, 20mg, 30mg

13

Antibiotic

Sulbactam 250 +
ampicillin 125
Sulbactam 500 +
ampicillin 250
Sulbactam 1000 +
ampicillin 500

Penicillin (100,000 unit/kg)

Penicillin G (3 L.E): vial 1,000,000 units for strept. Infection 10

times more potent than other penicillins

Tablets: ospen (1000)1000,000 (4.5 L.E) per tablet 10

Benzathine penicillin

Trade name: Durapen-S (5 L.E), lastipen (2.75 L.E), penadur

(4.10 L.E), penicid L.A (1.50 L.E), retarpen (4.50 L.E),
pencitard (3.75 L.E)

All are vial 1,200,000 IU

Dose

Less than 27 Kg vial every 2 weeks

More than 27 Kg 1 vial every 2 weeks

Ampicillin (50-100 mg/kg/day)

Oral not effective less than 40% are absorbed from GIT

Good with shigella infection

As injection

Ampictam (3, 7.75,

11.75)
Sulbin (4, 6.50, 9.25)
Synerpen (4, 6.60, 9.75)
Unasyn (8, 12, 17)
Unictam (3.75, 6, 11)

Amoxicillin
250mg/5ml

Amoxicillin
200mg/5ml

750
1500

Amoxicillin (50-100 mg/kg/day)

Amoxicillin
125mg/5ml

375

Oral syrup

Augmentin (18, 28,

37)
Curam (14, 21, 30)
Emox-clav
Hibiotic
Klavox
Magna-biotic
+
Megamox

156

312

625
228

14

Amoxicillin
400mg/5ml

Deltaclav
457
Amoxilanic
Augmacillin
Good for salmonella

Cephalosporin (50-100 mg/kg/day)

Painful so with IM solvent is lidocaine

If IM is given IV it will lead to cardiac arrythemia, arrest

Gentamycin (5-7 mg/kg/day)

Amikacin (15mg/kg/day)

-ve and anti-staph

Erythromycin (30-50 mg/kg/day)

Erythrocin 200mg/5ml 1

Azithromycin (10mg/kg/day)

100mg/5ml 1 2

200 mg/5ml 1 4

Clarithromycin

125 mg/5ml 5 8

250 mg/5ml 5 16

Flagyl

Ceftriaxone 3rd generation

5 4

Antipyretic

Paracetamol (10 mg/kg/dose every 4-6 hours)

Cetal syrup (250 mg/5ml0

Cetal drops: 3

Ibuprofen (10-15 mg/kg/dose every 8-12 hours) maximum

(40mg/kg/day)

Diclofenac (0.5-1 mg/kg/dose) maximum (2mg/kg/day)

No suppositories before 6 months

Paracetamol + ibuprofen

15

1 2

Steroids

Hydrocortisone (5-10 mg/kg/dose every 4-6 hours)

Dexamethasone (0.25-0.5 mg/kg/dose every 8-12 hours)

Contraindicated

Aspirin

Chloramphenicol

Tetracycline

Convulsions
1st attack

Diazepam (0.5 mg/kg/dose)

Neuril 10 mg/2ml

IV

Rectal by insulin syringe 10 100

Cause

Febrile convulsions

6 months 5 years

Once per disease

Recurrence 15% in another disease

In all not more than 2-3 times in all age: 3

EEG is normal

Atypical febrile convulsions

Treated as a case of epilepsy

Metabolic

Hypocalcemia

feeding:

Endocrinal problem

16

Carpo-pedal spasm

Invest: Serum Ca

TTT: Ca gluconate 10% 1cm/kg over 10 minutes

Vit D orally 5000 unit/day

Hypo, hyper natermia

GE, dehydration

Hypoglycemia

Serum glucose < 45

First attack of epilepsy

Organic brain lesion: CP, encephalitis

Pediatric clinic 3 march 2011

Antibiotics Penicillins
Natural penicillin
Dose: 50,000unit/kg/day
:Indications
Eradication of post strept. GN, ASO titer 444

Rheumatic fever

Types
Procaine penicillin
Trade name and formula: Retarpen, Durapen, pencitard (1,000,000 units per vial)
In meningitis dose is 100,000 200,000 units/kg/day

Unstable injection used only once

( 10 ) Used for 10 days

Benzathine penicillin (50,000 -100,000 units/kg/day)

Penicillin G 1,200,000 unit per vial IM only

Painful in injection

Phenoxy methyl penicillin (25,000 50,000 units/kg/day)

Oral Penicillin V

Used in URI

If patient refuse injection or doesnt tolerate injection

Trade name and dosage

Ospen 400,000 unit/5ml

400 = 5 = 5

80 5400 1 = 1
Dose: 40,000 units/kg/day

2 1
2 1

2/

( 8 )3

Clacil 300,000 units/5ml

17

Every 1 ml = 60,000 units

30

Dose: 30,000 units/kg/day

2 1

Taste is very bad

Synthetic penicillins (broad spectrum)

Ampicillin, amoxicillin (IV, IM, Oral)
Ampicillin (dose 50 100 mg/kg/day)
Dose for injection (IM or IV): 100 mg/kg/day

Dose for oral (suspension, caps): 50 mg/kg/day

Injection

Trade name and formula: ampicillin 250 mg / 50 mg / 1 g

Oral

Trade name and formula

2
mg/5ml 125
1
250
Ampicillin
2
500
Any antibiotic must be given for 7 days at least

To calculate average weight for child by age (from 1 6 years): (age 2) + 8

The half life time for synthetic penicillins is 6 8 hours

All antibiotic injections are unstable except 3rd generation cephalosporin

For example
Tonsillitis in 1 years old kid
WT= 12+8 = 4+8 = 10 kg
For injection = 1000 mg/day
12 Ampicillin 500 IM
For oral: 500 mg/day
7 8 Ampicillin 250 Susp 3.5
Amoxicillin (25 50 mg/kg/day)
Trade name and formula

Injection: amoxicillin, E-Mox 250, 500, 1 g

Oral: amoxicillin, E-Mox (125mg/5ml, 250mg/5ml)

Antistaph
Used mainly in pneumonia with pleural effusion

Ampicillin + (Flucloxacillin, Dicloxacillin, Cloxacillin)

Amoxicillin + Flucloxacillin (Flumox, Amoflux, Famox, Flucamox)

Flumox is very painful as IM injection and

( ) Very bad taste as suspension

Penicillin combination
Ampicillin + sulbactam (150 mg/kg/day for whole Combination)
Injection
mg 375
Unasyn
Unictam
mg 750
Sulbin
mg 1500

18

 Oral: Unasyn, Unictam 250 mg/5ml 1

Amoxicillin + clavulinic (40 - 50 mg/kg/day for amoxicillin concentration)
Oral
2
125mg/5ml =156
Augmentin
Curam
1
mg/5ml 250 =312
Emox-clav
1

200mg/5ml = 228.5

mg/5ml 400 = 457

1
2
3

mg/5ml 200 = 230

mg/5ml 400 = 460
mg/5ml 600 = 600

Megamox
Deltaclav
Augmacillin
Hibiotic - N

Giardia lamblia

Macrolides

Nifuroxazide

Flagyl: Constipation, GIT upset

Milk types
Bebelac 1 1 6
bebelac 2 2 6
cow milk 6
2
AS26 Bebelac PT PT
30/
4
free fatty acids 1gm = 9 calories
Appetite
Lactose intolerance
Bebelac FL

19

Pneumonia
Definition
Lower respiratory tract + lung parenchyma

Causes

Bacterial: staph, strept, pneumococci, haemophilus influenza,

Klebsiella, mycoplasma

Viral: Para-influenza viruses, adenovirus, RSV

Fungal: rare

Stages: 3 stages

Inflammation: edema + secretion " red"

Consolidation: fibrin deposition "grey"

Resolution: lipotropic factors

Symptoms
General:
High grade fever

Severe bronchospasm

Respiratory distress grade 4

Severe cough: spasmodic cough esp. if atypical pneumonia

Chest
Air entry

Adventitious sounds: sibilant or sonorous rhonchi

Stage of consolidation bronchial breathing

Fine crepitation

Types: According to Chest X-Ray

Patchy pneumonia

Lobar pneumonia

Perihilar pneumonia cotton fluffy appearance

X-ray: normal in 4 months child interstitial pneumonitis no

consolidation patches mostly viral infection

20

Other investigations

ABG for respiratory failure

H.R

Urea & creatinine

Treatment

Cyanosis respiratory failure = oxygenation

Nebulizer: as mucolytic

Atrovent if severe bronchospasm: Side effects:

tachycardia

There is no limited number for nebulizer sessions (in status

asthmaticus:

IV fluids: Maintenance therapy

100 10

50 10

20 10

5 %

100 1

To avoid volume overload heart failure, pulmonary

congestion, brain Edema

Fluid restriction by 20% or 30%:

0.8

feeding

Respiratory distress tachypnea aspiration

Tubal feeding

Antibiotics

Against G +ve: Penicillins : ampicillin, amoxicillin

G ve: 3rd generation cephalosporins

21

3-4 months atypical pneumonia "mycoplasma &

Klebsiella"

: Macrolides & Aminoglycosides

: Protein synthesis

Flagyl for anaerobic bacteria

Imipenem:

Anti-staph

Ampicillin + flucloxacillin

Gentamycin

Vancomycin dose: 12mg/kg/dose

Heart failure: transient except if congenital heart disease

Tachycardia, tachypnea, tender enlarged liver

Treatment

Frusemide: Lasix 1mg/kg/day

Lasix 20mg/2ml

12

To decrease afterload: Capoten: dose 0.5-5mg/kg/day

2 mg/kg/day

12.5 25

12 1

Digitalis:

Loading dose: 0.05mg/kg or (50g /kg)

Maintenance dose: 0.01mg/kg/day or (10g/kg/day)

22

Digitalizing dose: 50g/kg

Digitalis is contraindicated in: obstructive lesions as in M.S

Don't tire tired horse

Pulmonary stenosis

Cardiomyopathy

Hypertrophic Obstructive Cardiomyopathy (HOCM)

infant of diabetic mother (As insulin deposition of
phospholipids in the septum)
Inderal

Any neonate with cough in the first 4 months is considered

pneumonia until proved otherwise

Treated as pneumonia in the outpatient:

Antibiotics course for 7-10 days at least

G-ve injection

G +ve

Oral macrolides: azithromycin or erythromycin

Amoxicillin + clavulinic acid

Cough depressant

Herbal

Active respiratory infection

After 1 year

Cough sedative for dry cough or pertussis

All doses are: 1-2mg/kg/day except 1 drug

23

2P 2B 1C DONE
2P

Pholcodine 0.5-1 mg/kg/day

Cyrinol 4mg/5ml 0.7mg/1ml 0.7mg/kg/day

1ml/kg/day 1

Pipazethate 1-2mg/kg/day

Selgon

Suppositories 10mg ) 10
(

Drops 40mg/1ml every 1 ml =20 drops 40mg/20drops

2mg/drop 2mg/kg/day 1drop/kg/day

2B

Butamirate 1-2mg/kg/day

Sinecod

Syrup 7.5mg/5ml 1.5mg/1ml 1.5mg/kg/day

1ml/kg/day 1

Drops: 0.5mg/drop 4

Other trade name: Cough cut syrup: 1

Benproperine 1-2mg/kg/day

Pectipro syrup 10mg/5ml 2mg/1ml 2mg/kg/day 1

1C

Colbutinol 1-2mg/kg/day

Silomat (drops, syrup, injection)

DON

Dextromethorphan 1-2mg/kg/day

Codilar 7.5mg/5ml 1

Pulmonal-N 1

Oxeladine

24

Oxeladine syrup 10mg/5ml 1

Paxeladine

Noscapine

Tusscapine syrup 1

25